Fenestrated implant

ABSTRACT

The present invention relates generally to implants used in medical procedures such as bone fixation or fusion. More specifically, this application relates to fenestrated implants used in bone fixation or fusion.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.17/649,544, filed on Jan. 31, 2022, which is a continuation U.S.application Ser. No. 16/552,912, filed Aug. 27, 2019, now U.S. Pat. No.11,291,485, which is a continuation of U.S. application Ser. No.13/888,249, filed May 6, 2013, now U.S. Pat. No. 10,426,533, whichclaims the benefit of U.S. Provisional Application No. 61/642,681, filedMay 4, 2012, titled “FENESTRATED IMPLANT”, each of which is hereinincorporated by reference in its entirety for all purposes.

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specificationare herein incorporated by reference to the same extent as if eachindividual publication or patent application was specifically andindividually indicated to be incorporated by reference. For example,this application incorporates by reference in their entireties U.S.Patent Publication No. 2011/0087294 and U.S. Patent Publication No.2011/0118785.

FIELD

This application relates generally to implants used in medicalprocedures such as bone fixation or fusion. More specifically, thisapplication relates to fenestrated implants used in bone fixation orfusion.

BACKGROUND

Many types of hardware are available both for the fixation of bones thatare fractured and for the fixation of bones that are to be fused(arthrodesed).

For example, the human hip girdle is made up of three large bones joinedby three relatively immobile joints. One of the bones is called thesacrum and it lies at the bottom of the lumbar spine, where it connectswith the L5 vertebra. The other two bones are commonly called “hipbones” and are technically referred to as the right ilium and-the leftilium. The sacrum connects with both hip bones at the sacroiliac joint(in shorthand, the SI-Joint).

The SI-Joint functions in the transmission of forces from the spine tothe lower extremities, and vice-versa. The SI-Joint has been describedas a pain generator for up to 22% of lower back pain.

To relieve pain generated from the SI Joint, sacroiliac joint fusion istypically indicated as surgical treatment, e.g., for degenerativesacroiliitis, inflammatory sacroiliitis, iatrogenic instability of thesacroiliac joint, osteitis condensans ilii, or traumatic fracturedislocation of the pelvis. Currently, screws and screws with plates areused for sacro-iliac fusion.

In order to promote bone growth into the implant and enhance fusion ofthe implant with the bone, pockets or channels can be created in theimplant that promote bone growth into the implant. However, thesepockets or channels may weaken the structural integrity of the implant,which can also be required to bear large stresses. Therefore, it wouldbe desirable to provide an implant with pockets or channels to promotebone growth while substantially maintaining the structural integrity ofthe implant.

SUMMARY OF THE DISCLOSURE

The present invention relates generally to implants used in medicalprocedures such as bone fixation or fusion. More specifically, thisapplication relates to fenestrated implants used in bone fixation orfusion.

In some embodiments, an implant for bone fixation is provided. Theimplant can include an elongate body having a longitudinal axis and arectilinear cross section transverse to the longitudinal axis, aplurality of faces, a plurality of apexes joining the plurality offaces, a central lumen extending along the longitudinal axis of theelongate body, and a plurality of holes with openings on the pluralityof faces, wherein the holes are in fluid communication with the centrallumen.

In some embodiments, the holes are circular. In some embodiments, theholes are oval. In some embodiments, the holes are arranged in a singlelongitudinal row on each face. In some embodiments, the holes arearranged in a plurality of longitudinal rows on each face.

In some embodiments, the elongate body is coated with a biologic aid.

In some embodiments, the holes have a diameter that is about equal tothe diameter of the central lumen. In some embodiments, the holes have adiameter than is between about 0.2 to 0.5 of the width of the faces.

In some embodiments, an implant for bone fixation is provided. Theimplant can include an elongate body having a longitudinal axis and arectilinear cross section transverse to the longitudinal axis, aplurality of faces, a plurality of apexes joining the plurality offaces, a central lumen extending along the longitudinal axis of theelongate body, and a plurality of side pockets extending along a portionof each of the plurality of faces, wherein the side pockets have a depththat does not extend to the central lumen.

In some embodiments, each of the plurality of faces has only one sidepocket. In some embodiments, each of the side pockets is centered oneach of the faces. In some embodiments, the side pockets have a widththat is between about 0.2 to 0.8 of the width of the faces and a lengththat is between about 0.5 to 0.9 of the length of the faces.

In some embodiments, the implant further includes a plurality of holeslocated within the side pockets, wherein the holes are in fluidcommunication with the central lumen.

In some embodiments, an implant for bone fixation is provided. Theimplant can include an elongate body having a longitudinal axis and arectilinear cross section transverse to the longitudinal axis, aplurality of faces, a plurality of apexes joining the plurality offaces, and a central lumen extending along the longitudinal axis of theelongate body, wherein each one of the plurality of apexes includes agroove that extends along the length of the apex.

In some embodiments, an implant for bone fixation is provided. Theimplant can include an elongate body having a longitudinal axis and arectilinear cross section transverse to the longitudinal axis, aplurality of faces, a plurality of apexes joining the plurality offaces, and a central lumen extending along the longitudinal axis of theelongate body, wherein each one of the plurality of apexes includes aplurality of pockets located at discrete points along the length of eachapex.

In some embodiments, an implant for bone fixation is provided. Theimplant can include an elongate body having a longitudinal axis, adistal end, a proximal end, and a rectilinear cross section transverseto the longitudinal axis, a plurality of faces, each face formed from awall with a thickness between about 2 to 3 mm in thickness, and aplurality of fenestrations disposed on each face.

In some embodiments, the distal end of the elongate body is formed intoone or more cutting edges.

In some embodiments, the rectilinear cross section has three sides. Insome embodiments, the rectilinear cross section has four sides, such asin FIG. 8C.

In some embodiments, the fenestrations are located on a distal portionof the elongate body that is configured to be implanted within thesacrum of a patient while the proximal portion of the elongate body thatis configured to be implanted within the illium is free fromfenestrations.

In some embodiments, the fenestrations are arranged in a staggeredpattern.

In some embodiments, the implant further includes a cap on the proximalend of the elongate body, the cap having a hole sized to receive a guidepin.

In some embodiments, the elongate body has an inner surface and an outersurface that are porous. In some embodiments, the elongate body has aninner surface and an outer surface that are roughened. In someembodiments, the elongate body has an inner surface and an outer surfacethat are plasma coated. In some embodiments, the elongate body has aninner surface and an outer surface that are coated with a biologic aid.In some embodiments, the biologic aid is a bone morphogenetic protein.

BRIEF DESCRIPTION OF THE DRAWINGS

The novel features of the invention are set forth with particularity inthe claims that follow. A better understanding of the features andadvantages of the present invention will be obtained by reference to thefollowing detailed description that sets forth illustrative embodiments,in which the principles of the invention are utilized, and theaccompanying drawings of which:

FIGS. 1A-1V illustrate various embodiments of implant structures withdifferent fenestrations.

FIGS. 2A-2D are side section views of the formation of a broached borein bone according to one embodiment of the invention.

FIGS. 2E and 2F illustrate the assembly of a soft tissue protectorsystem for placement over a guide wire.

FIGS. 3 and 4 are, respectively, anterior and posterior anatomic viewsof the human hip girdle comprising the sacrum and the hip bones (theright ilium, and the left ilium), the sacrum being connected with bothhip bones at the sacroiliac joint (in shorthand, the SI-Joint).

FIGS. 5 to 7A and 7B are anatomic views showing, respectively, apre-implanted perspective, implanted perspective, implanted anteriorview, and implanted cranio-caudal section view, the implantation ofthree implant structures for the fixation of the SI-Joint using alateral approach through the ilium, the SI-Joint, and into the sacrum.

FIGS. 8A, 8B and 8C illustrate embodiments of implant structures withfenestrations.

FIGS. 9A and 9B illustrate yet another embodiment of an implantstructure with fenestrations.

DETAILED DESCRIPTION

Elongated, stem-like implant structures 20 like that shown in FIG. 1Amake possible the fixation of the SI-Joint (shown in anterior andposterior views, respectively, in FIGS. 3 and 4 ) in a minimallyinvasive manner. These implant structures 20 can be effectivelyimplanted through the use of a lateral surgical approach. The procedureis desirably aided by conventional lateral and/or anterior-posterior(A-P) visualization techniques, e.g., using X-ray image intensifierssuch as a C-arms or fluoroscopes to produce a live image feed that isdisplayed on a TV screen.

In some embodiments, the implant structures 20 can include pockets,pathways, cavities, openings, fenestrations, channels and/or recessesthat allow bone graft materials to be incorporated into the implantstructure. These bone graft materials can promote bone growth intoand/or around the implant structure, which can reduce the time it takesfor the implant structure to be stably integrated with the bone. Bonegraft materials can be applied to and/or injected into the implantstructure before implantation or applied after implantation by injectionof the bone graft material into a proximal cannula or other conduit. Insome embodiments, the surfaces of the implant structure 20 can beroughened or textured to promote bone growth and adherence of the bonegraft materials. The internal and/or external surfaces can be roughenedor textured by mechanical means or can be spray coated with a rougheningmaterial.

The bone graft materials can be a liquid, gel, slurry, paste, powder orother form, and can include a biologic aid that can promote and/orenhance bony ingrowth, tissue repair, and/or reduce inflammation,infection and pain. For example, the biologic aid can include growthfactors, such as bone morphogenetic proteins (BMPs), hydroxyapatite in,for example, a liquid or slurry carrier, demineralized bone, morselizedautograft or allograft bone, medications to reduce inflammation,infection or pain such as analgesics, antibiotics and steroids. In someembodiments, the growth factors can be human recombinant growth factors,such as hr-BMP-2 and/or hr-BMP-7, or any other human recombinant form ofBMP, for example. The carrier for the biologic aid can be a liquid orgel such as saline or a collagen gel, for example. The biologic aid canalso be encapsulated or incorporated in a controlled releasedformulation so that the biologic aid is released to the patient at theimplant site over a longer duration. For example, the controlled releaseformulation can be configured to release the biologic aid over thecourse of days or weeks or months, and can be configured to release thebiologic aid over the estimated time it would take for the implant siteto heal. The amount of biologic aid delivered to the implant structurecan be controlled using a variety of techniques, such as controlling orvarying the amount of coating material applied to the implant and/orcontrolling or varying the amount of biologic aid incorporated into thecoating material. In some embodiments, in may be important to controlthe amount of biologic aid delivered because excessive use of certainbiologic aids can result in negative effects such as radicular pain, forexample.

In general, any pockets, pathways, cavities, openings, fenestrations,channels and/or recesses in the implant structure may weaken itsstructural strength, including for example the bending and shearstrengths. The following examples of implant structures are variationsof the solid triangular implant structure 20 of FIG. 1A, which has asingle central, longitudinally oriented lumen or cannula for receiving aguide wire or guide pin. The relative bending and shear strengths can becompared to the cannulated but otherwise solid implant structure 20 ofFIG. 1A, which can be assigned a bending strength of 1.00 and a shearstrength of 1.00. The relative bending and shear strengths can bemodified or optimized for structural strength and ability to promotebone grafting by varying the size, number, spacing, location,orientation, and shape of the pockets, pathways, cavities, openings,fenestrations, channels and/or recesses. Although the embodimentsillustrated herein show triangular implant structures, implantstructures with different rectilinear shapes, such as rectangular orsquare, can be used or substituted for the triangular implantstructures.

FIGS. 1B-D illustrate an embodiment of a triangular implant structure100 having a central lumen 101 and a series of holes 102 on each face103 of the implant structure 100 that reach and provide access to thecentral lumen 101. The holes 102 can be centered on the face 103 andextend inwardly at an angle that is substantially perpendicular ornormal to the face 103 of the implant structure 100. In someembodiments, each apex 104 can be beveled or rounded. In someembodiments, the distal end 105 of the implant structure 100 can betapered to facilitate implantation into the bone. In some embodiments,the diameter of the holes 102 can be equal to or substantially equal tothe diameter of the central lumen 101. In other embodiments, thediameter of the holes 102 can be greater than or less than the diameterof the central lumen 101. In some embodiments, the implant structure 100illustrated in FIGS. 1B-D has a relative bending strength of about 0.82and a relative shear strength of about 0.66. In some embodiments, toinject or load the implant structure 100 with bone graft materials, thedistal hole 106 of the central lumen 101 can be blocked or sealed sothat flow of the bone graft materials fills the central lumen 101 andexits the side holes 102.

In some embodiments, the holes 102 can have a diameter (D1) that isabout 0.3 of width (W1) of the face 103 of the implant structure 100. Insome embodiments, the holes 102 can have a diameter that is greater thanabout 0.3 of the width of the face 103 of the implant structure 100. Insome embodiments, the holes 102 can have a diameter that is less thanabout 0.3 of the width of the face 103 of the implant structure 100. Insome embodiments, the holes 102 can have a diameter that is betweenabout 0.2 to about 0.5 of the width of the face 103 of the implantstructure. In some embodiments, the holes 102 can be separated fromadjacent holes 102 by about ⅔ of the hole diameter, where separationdistance (S1) is measured by the distance between the circumference ofthe holes 102. In some embodiments, the holes 102 can be separated fromadjacent holes 102 by less than about ⅔ of the hole diameter. In someembodiments, the holes 102 can be separated from adjacent holes 102 bygreater than about ⅔ of the hole diameter. In some embodiments, theholes 102 can be separated from adjacent holes 102 by about 0.5 to about2 times, or about 0.5 to about 1 times the hole 102 diameter. In someembodiments, the relative bending strength can be at least about 0.5,0.6, 0.7, 0.8 or 0.9. In some embodiments, the relative bending strengthcan be between about 0.5 to 0.9. In some embodiments, the relative shearstrength can be at least about 0.5, 0.6, 0.7, 0.8 or 0.9. In someembodiments, the relative shear strength can be between about 0.5 to0.9.

FIGS. 1E-G illustrate another embodiment of an implant structure 110having a central lumen 111 and a series of slots 112 on each face 113 ofthe implant structure 110 that reach and provide access to the centrallumen 111. The slots 112 can be centered on the face 113 and extendinwardly at an angle that is substantially perpendicular or normal tothe face 113 of the implant structure 110. In some embodiments, eachapex 114 can be beveled or rounded. In some embodiments, the distal end115 of the implant structure 110 can be tapered to facilitateimplantation into the bone. In some embodiments, the width of the slotscan be equal to or substantially equal to the diameter of the centrallumen 111. In other embodiments, the width of the slots can be greaterthan or less than the diameter of the central lumen 111. In someembodiments, the implant structure 110 illustrated in FIGS. 1E-G has arelative bending strength of about 0.82 and a relative shear strength ofabout 0.66. In some embodiments, to inject or load the implant structure110 with bone graft materials, the distal hole 116 of the central lumen111 can be blocked or sealed so that flow of the bone graft materialsfills and exits the slots 112.

In some embodiments, the slots 112 can have a width (W3) that is about0.3 of width (W2) of the face 113 of the implant structure 110. In someembodiments, the slots 112 can have a width that is greater than about0.3 of the width of the face 113 of the implant structure 110. In someembodiments, the slots 112 can have a width that is less than about 0.3of the width of the face 113 of the implant structure 110. In someembodiments, the slots 112 can have a width that is between about 0.2 toabout 0.6 of the width of the face 113 of the implant structure 110. Insome embodiments, the slots 112 can have a length (L3) that is about0.15 the length (L2) of the face 113. In some embodiments, the slots 112can have a length that is less than about 0.15 the length of the face113. In some embodiments, the slots 112 can have a length that isgreater than about 0.15 the length of the face 113. In some embodiments,the slots 112 can have a length that is between about 0.1 to 0.4, orabout 0.1 to 0.25 the length of the face 113. In some embodiments, theslots 112 are separated (S2) from adjacent slots 112 by about ⅔ thewidth of the slot 112. In some embodiments, the slots 112 are separatedfrom adjacent slots 112 by greater than about ⅔ the width of the slot112. In some embodiments, the slots 112 are separated from adjacentslots 112 by less than about ⅔ the width of the slot 112. In someembodiments, the slots 112 can be separated from adjacent slots 112 byabout 0.5 to about 2 times, or about 0.5 to about 1 times the slot 112width. In some embodiments, the relative bending strength can be atleast about 0.5, 0.6, 0.7, 0.8 or 0.9. In some embodiments, the relativebending strength can be between about 0.5 to 0.9. In some embodiments,the relative shear strength can be at least about 0.5, 0.6, 0.7, 0.8 or0.9. In some embodiments, the relative shear strength can be betweenabout 0.5 to 0.9.

FIGS. 1H-J illustrate another embodiment of an implant structure 120having a central lumen 121 and a side pocket 122 on each face 123 of theimplant structure 120. The side pocket 122 can be a depression, cavity,groove or slot centered on the face 123 having a width, length anddepth. In some embodiments, the side pocket 122 is relatively shallow sothat it does not extend to the central lumen 121. In some embodiments,each apex 124 can be beveled or rounded. In some embodiments, the distalend 125 of the implant structure 120 can be tapered to facilitateimplantation into the bone. In some embodiments, the implant structure120 illustrated in FIGS. 1H-J has a relative bending strength of about0.77 and a relative shear strength of about 0.72. In some embodiments,to load the implant structure 120 with bone graft materials, the bonegraft material is applied to the side pockets 122 before implantation.In other embodiments, the bone graft material is applied duringimplantation, as further described in U.S. Patent Application 61/609,043titled Tissue Dilator and Protector, which is hereby incorporated byreference in its entirety and can be applied to the other implants.

In some embodiments, the side pocket 122 can have a width (W4) that isabout 0.5 of width (W5) of the face 123 of the implant structure 120. Insome embodiments, the side pocket 122 can have a width that is greaterthan about 0.5 of the width of the face 123 of the implant structure120. In some embodiments, the side pocket 122 can have a width that isless than about 0.5 of the width of the face 123 of the implantstructure 120. In some embodiments, the side pocket 122 can have a widththat is between about 0.2 to about 0.8 of the width of the face 123 ofthe implant structure 120. In some embodiments, the side pocket 122 canhave a length (L4) that is about 0.75 the length (L5) of the face 123.In some embodiments, the side pocket 122 can have a length that is lessthan about 0.75 the length of the face 123. In some embodiments, theside pocket 122 can have a length that is greater than about 0.75 thelength of the face 123. In some embodiments, the side pocket 122 canhave a length that is between about 0.5 to 0.9 of the length of the face123. In some embodiments, the side pocket 122 can have a depth betweenabout 0.2 mm and 5 mm, or between about 0.2 mm and 2 mm, or betweenabout 0.2 and 1 mm. In some embodiments, the side pocket 122 can have adepth between about 0.25 mm, 0.5 mm, 0.75 mm, 1 mm or 2 mm. In someembodiments, the relative bending strength can be at least about 0.5,0.6, 0.7, 0.8 or 0.9. In some embodiments, the relative bending strengthcan be between about 0.5 to 0.9. In some embodiments, the relative shearstrength can be at least about 0.5, 0.6, 0.7, 0.8 or 0.9. In someembodiments, the relative shear strength can be between about 0.5 to0.9.

FIGS. 1K-M illustrate another embodiment of an implant structure 130having a central lumen 131, a side pocket 132 on each face 133 of theimplant structure 130, and a plurality of holes 134 located within theside pocket 132. The side pocket 132 in the embodiment illustrated inFIGS. 1K-M can be the same as or be similar to the side pocket 122previously described above and illustrated in FIGS. 1H-J. Likewise, theholes 134 illustrated in FIGS. 1K-M can be the same as or be similar tothe holes 102 previously described above and illustrated in FIGS. 1B-D.In some embodiments, as illustrated in FIGS. 1K-M, the holes 134 have adiameter that is less than the diameter of the central lumen 131. Inother embodiments, the holes 134 have a diameter than is equal to orgreater than the diameter of the central lumen 131. In some embodiments,each apex 135 can be beveled or rounded. In some embodiments, the distalend 136 of the implant structure 130 can be tapered to facilitateimplantation into the bone. In some embodiments, the implant structure130 illustrated in FIGS. 1K-M has a relative bending strength of about0.74 and a relative shear strength of about 0.62. In some embodiments,to load the implant structure 130 with bone graft materials, the bonegraft material is injected and/or applied to the side pockets 132 andholes 134 before implantation. In other embodiments, the bone graftmaterials can be injected into the central lumen 131, which can have adistal opening 137 that is blocked off or plugged so that the bone graftmaterials fill the central lumen 131 and exit out the holes 134 whichare in fluid communication with the central lumen 131. As the bone graftmaterials exit the holes 134, the bone graft material can coat and fillboth the holes 134 and the side pocket 132. This injection process canbe done before implantation, during implantation, or after implantation.

In some embodiments, the side pocket 132 shown in FIGS. 1K-M has thesame or similar dimensions as the side pocket 122 shown in FIGS. 1H-Jand described above. In some embodiments, the holes 134 can have adiameter (D2) that is about 0.4 of the width (W6) of the side pocket132. In some embodiments, the holes 134 can have a diameter that isgreater than or less than about 0.4 times the width of the side pocket132. In some embodiments, the holes 134 can be separated (S3) by about1.5 times the diameter of the holes 134. In some embodiments, the holes134 can be separated by greater than or less than about 1.5 times thediameter of the holes 134. In some embodiments, the relative bendingstrength can be at least about 0.5, 0.6, 0.7, 0.8 or 0.9. In someembodiments, the relative bending strength can be between about 0.5 to0.9. In some embodiments, the relative shear strength can be at leastabout 0.5, 0.6, 0.7, 0.8 or 0.9. In some embodiments, the relative shearstrength can be between about 0.5 to 0.9.

FIGS. 1N-P illustrate another embodiment of an implant structure 140having a central lumen 141 and a plurality of peripheral lumens 142surrounding the central lumen 141. The peripheral lumens 142 can beoriented longitudinally and can be located between the central lumen 141and each apex 143. As illustrated, the implant structure 140 istriangular and has three apexes 143 and three peripheral lumens 142 thatsurround the central lumen 141. In some embodiments, both the centrallumen 141 and the peripheral lumens 142 can extend throughout thelongitudinal length of the implant structure 140. In other embodiments,the peripheral lumens 142 do not extend throughout the length of theimplant structure 140, and instead, the peripheral lumens 142 terminateprior to the distal end 144 of the implant structure 140. In addition, aplurality of side holes 145 can be included in the implant structure140. Each peripheral lumen 142 can be intersected by a plurality of sideholes 145, where each side hole 145 extends between two faces 146 of theimplant structure with a side hole opening 147 on each of the two faces146. The side holes 145 can extend transversely through the implantstructure 140 at an angle of about 60 degrees from the surfaces of thefaces 146. In some embodiments, each apex 143 can be beveled or rounded.In some embodiments, the distal end 144 of the implant structure 140 canbe tapered to facilitate implantation into the bone. In someembodiments, the implant structure 140 illustrated in FIGS. 1N-P has arelative bending strength of about 0.63 and a relative shear strength ofabout 0.66. In some embodiments, to load the implant structure 140 withbone graft materials, the bone graft material is injected into theperipheral lumens 142, where the bone graft material fills up theperipheral lumens and exits the side holes 145. Injection of the bonegraft material can take place before, during, or after implantation. Insome embodiments where the peripheral lumens 142 extend completelythrough the implant structure 140, the distal ends of the peripherallumens 142 can be blocked or plugged before injection of the bone graftmaterial.

In some embodiments, the peripheral lumens 142 have a diameter (D3) ofabout 0.2 times the width (W7) of the faces 146 of the implantstructure. In some embodiments, the peripheral lumens 142 have adiameter greater than or less than about 0.2 times the width of thefaces 146 of the implant structure. In some embodiments, the peripherallumens 142 can have a smaller diameter than the central lumen 141. Inother embodiments, the peripheral lumens 142 can have an equal or largerdiameter than the central lumen 141. In some embodiments, the side holes145 have a diameter (D4) equal or substantially equal to the diameter ofthe peripheral lumens 142. In other embodiments, the side holes 145 havea diameter less than or greater than the diameters of the peripherallumens 142. In some embodiments, the relative bending strength can be atleast about 0.5, 0.6, 0.7, 0.8 or 0.9. In some embodiments, the relativebending strength can be between about 0.5 to 0.9. In some embodiments,the relative shear strength can be at least about 0.5, 0.6, 0.7, 0.8 or0.9. In some embodiments, the relative shear strength can be betweenabout 0.5 to 0.9.

FIGS. 1Q-S illustrate another embodiment of an implant structure 150having a central lumen 151. Each apex 152 can be beveled or rounded andcan have a plurality of pockets or cavities 153 located at discretepoints along the length of the apex 152. These pockets 153 extend fromthe apex 152 and towards the central lumen 151, but do not reach thecentral lumen 151. In some embodiments, the pockets 153 have a curvedcutout shape, which can correspond in shape to a portion of a cylinder.In some embodiments, the distal end 154 of the implant structure 140 canbe tapered to facilitate implantation into the bone. In someembodiments, the implant structure 150 illustrated in FIGS. 1Q-S has arelative bending strength of about 0.89 and a relative shear strength ofabout 0.86. In some embodiments, to load the implant structure 150 withbone graft materials, the bone graft material is applied externally tothe implant structure 150 either before or during implantation. Inaddition to receiving the bone graft materials, the pockets 153 alsofunction to eliminate or reduce a corner haloing effect.

In some embodiments, the pockets 153 can have a length (L6) or diameterof about 0.06 of the length (L7) of the apex 152. In some embodiments,the pockets 153 can have a length or diameter greater than or less thanabout 0.06 of the length of the apex 152. In some embodiments, thepockets 153 can be separated (S4) from adjacent pockets 153 by about ⅔of the pocket length or diameter. In some embodiments, the pockets 153can be separated from adjacent pockets 153 by greater than or less thanabout ⅔ of the hole diameter. In some embodiments, the relative bendingstrength can be at least about 0.5, 0.6, 0.7, 0.8 or 0.9. In someembodiments, the relative bending strength can be between about 0.5 to0.95. In some embodiments, the relative shear strength can be at leastabout 0.5, 0.6, 0.7, 0.8 or 0.9. In some embodiments, the relative shearstrength can be between about 0.5 to 0.95.

FIGS. 1T-V illustrate another embodiment of an implant structure 160having a central lumen 161. Each apex 162 has a groove 163 that extendsalong the length of the apex 162. In some embodiments, the distal end164 of the implant structure 160 can be tapered to facilitateimplantation into the bone. In some embodiments, the implant structure160 illustrated in FIGS. 1T-V has a relative bending strength of about0.87 and a relative shear strength of about 0.88. In some embodiments,to load the implant structure 160 with bone graft materials, the bonegraft material is applied externally to the implant structure 160 eitherbefore or during implantation. In addition to receiving the bone graftmaterials, the grooves 163 also function to eliminate or reduce a cornerhaloing effect.

In some embodiments, the grooves 163 can be circular shaped cutoutsrunning along the apex 162 having a diameter (D5) of about 0.25 of thewidth of the face 165 and an arc length of about 0.28 of the width ofthe face 165. In some embodiments, the grooves 163 can have a diameterof greater or less than about 0.25 of the width of the face 165. In someembodiments, the grooves 163 can have an arc length of greater than orless than about 0.28 of the width of the face 165.

In one embodiment of a lateral approach (see FIGS. 5, 6, and 7A/B), oneor more implant structures 20 are introduced laterally through theilium, the SI-Joint, and into the sacrum. This path and resultingplacement of the implant structures 20 are best shown in FIGS. 6 and7A/B. In the illustrated embodiment, three implant structures 20 areplaced in this manner. Also in the illustrated embodiment, the implantstructures 20 are rectilinear in cross section and triangular in thiscase, but it should be appreciated that implant structures 20 of othercross sections can be used. In addition, any of the implant structuresdisclosed above can be used in the implantation procedures herein.

Before undertaking a lateral implantation procedure, the physicianidentifies the SI-Joint segments that are to be fixated or fused(arthrodesed) using, e.g., the Fortin finger test, thigh thrust, FABER,Gaenslen's, compression, distraction, and diagnostic SI Joint injection.

Aided by lateral, inlet, and outlet C-arm views, and with the patientlying in a prone position, the physician aligns the greater sciaticnotches and then the alae (using lateral visualization) to provide atrue lateral position. A 3 cm incision is made starting aligned with theposterior cortex of the sacral canal, followed by blunt tissueseparation to the ilium. From the lateral view, the guide pin 38 (withsleeve (not shown)) (e.g., a Steinmann Pin) is started resting on theilium at a position inferior to the sacrum end plate and just anteriorto the sacral canal. In the outlet view, the guide pin 38 should beparallel to the sacrum end plate at a shallow angle anterior (e.g., 15to 20 degrees off horizontal, as FIG. 7B shows). In a lateral view, theguide pin 38 should be posterior to the sacrum anterior wall. In theinlet view, the guide pin 38 should not violate the sacral foramina.This corresponds generally to the sequence shown diagrammatically inFIGS. 2A and 2B. A soft tissue protector (not shown) is desirablyslipped over the guide pin 38 and firmly against the ilium beforeremoving the guide pin sleeve (not shown).

Over the guide pin 38 (and through the soft tissue protector), the pilotbore 42 is drilled in the manner previously described, as isdiagrammatically shown in FIG. 2C. The pilot bore 42 extends through theilium, through the SI-Joint, and into the sacrum. The drill bit 40 isthen removed.

The shaped broach 44 is tapped into the pilot bore 42 over the guide pin38 (and through the soft tissue protector) to create a broached bore 48with the desired profile for the implant structure 20, which, in theillustrated embodiment, is triangular. This generally corresponds to thesequence shown diagrammatically in FIG. 2D. The triangular profile ofthe broached bore 48 is also shown in FIG. 5 .

FIGS. 2E and 2F illustrate an embodiment of the assembly of a softtissue protector or dilator or delivery sleeve 200 with a drill sleeve202, a guide pin sleeve 204 and a handle 206. In some embodiments, thedrill sleeve 202 and guide pin sleeve 204 can be inserted within thesoft tissue protector 200 to form a soft tissue protector assembly 210that can slide over the guide pin 208 until bony contact is achieved.The soft tissue protector 200 can be any one of the soft tissueprotectors or dilators or delivery sleeves disclosed herein. In someembodiments, an expandable dilator or delivery sleeve 200 as disclosedherein can be used in place of a conventional soft tissue dilator. Inthe case of the expandable dilator, in some embodiments, the expandabledilator can be slid over the guide pin and then expanded before thedrill sleeve 202 and/or guide pin sleeve 204 are inserted within theexpandable dilator. In other embodiments, insertion of the drill sleeve202 and/or guide pin sleeve 204 within the expandable dilator can beused to expand the expandable dilator.

In some embodiments, a dilator can be used to open a channel though thetissue prior to sliding the soft tissue protector assembly 210 over theguide pin. The dilator(s) can be placed over the guide pin, using forexample a plurality of sequentially larger dilators or using anexpandable dilator. After the channel has been formed through thetissue, the dilator(s) can be removed and the soft tissue protectorassembly can be slid over the guide pin. In some embodiments, theexpandable dilator can serve as a soft tissue protector after beingexpanded. For example, after expansion the drill sleeve and guide pinsleeve can be inserted into the expandable dilator.

As shown in FIGS. 5 and 6 , a triangular implant structure 20 can be nowtapped through the soft tissue protector over the guide pin 38 throughthe ilium, across the SI-Joint, and into the sacrum, until the proximalend of the implant structure 20 is flush against the lateral wall of theilium (see also FIGS. 7A and 7B). The guide pin 38 and soft tissueprotector are withdrawn, leaving the implant structure 20 residing inthe broached passageway, flush with the lateral wall of the ilium (seeFIGS. 7A and 7B). In the illustrated embodiment, two additional implantstructures 20 are implanted in this manner, as FIG. 6 best shows. Inother embodiments, the proximal ends of the implant structures 20 areleft proud of the lateral wall of the ilium, such that they extend 1, 2,3 or 4 mm outside of the ilium. This ensures that the implants 1020engage the hard cortical portion of the ilium rather than just thesofter cancellous portion, through which they might migrate if there wasno structural support from hard cortical bone. The hard cortical bonecan also bear the loads or forces typically exerted on the bone by theimplant 1020.

The implant structures 20 are sized according to the local anatomy. Forthe SI-Joint, representative implant structures 20 can range in size,depending upon the local anatomy, from about 35 mm to about 70 mm inlength, and about a 7 mm inscribed diameter (i.e. a triangle having aheight of about 10.5 mm and a base of about 12 mm). The morphology ofthe local structures can be generally understood by medicalprofessionals using textbooks of human skeletal anatomy along with theirknowledge of the site and its disease or injury. The physician is alsoable to ascertain the dimensions of the implant structure 20 based uponprior analysis of the morphology of the targeted bone using, forexample, plain film x-ray, fluoroscopic x-ray, or MRI or CT scanning.

Using a lateral approach, one or more implant structures 20 can beindividually inserted in a minimally invasive fashion across theSI-Joint, as has been described. Conventional tissue access tools,obturators, cannulas, and/or drills can be used for this purpose.Alternatively, the novel tissue access tools described above and inco-pending U.S. Application No. 61/609,043, titled “TISSUE DILATOR ANDPROTECTER” and filed Mar. 9, 2012, can also be used. No jointpreparation, removal of cartilage, or scraping are required beforeformation of the insertion path or insertion of the implant structures20, so a minimally invasive insertion path sized approximately at orabout the maximum outer diameter of the implant structures 20 can beformed.

The implant structures 20 can obviate the need for autologous bone graftmaterial, additional screws and/or rods, hollow modular anchoragescrews, cannulated compression screws, threaded cages within the joint,or fracture fixation screws. Still, in the physician's discretion, bonegraft material and other fixation instrumentation can be used incombination with the implant structures 20.

In a representative procedure, one to six, or perhaps up to eight,implant structures 20 can be used, depending on the size of the patientand the size of the implant structures 20. After installation, thepatient would be advised to prevent or reduce loading of the SI-Jointwhile fusion occurs. This could be about a six to twelve week period ormore, depending on the health of the patient and his or her adherence topost-op protocol.

The implant structures 20 make possible surgical techniques that areless invasive than traditional open surgery with no extensive softtissue stripping. The lateral approach to the SI-Joint provides astraightforward surgical approach that complements the minimallyinvasive surgical techniques. The profile and design of the implantstructures 20 minimize or reduce rotation and micromotion. Rigid implantstructures 20 made from titanium alloy provide immediate post-op SIJoint stability. A bony in-growth region 24 comprising a porous plasmaspray coating with irregular surfaces supports stable bonefixation/fusion. The implant structures 20 and surgical approaches makepossible the placement of larger fusion surface areas designed tomaximize post-surgical weight bearing capacity and provide abiomechanically rigorous implant designed specifically to stabilize theheavily loaded SI-Joint.

In some embodiments, as illustrated in FIGS. 8A and 8B, the implantstructure 800 can have a rectilinear cross-sectional profile formed froma plurality of walls 802 having a thickness of approximately 2 to 3 mm,or 1 to 5 mm, or less than approximately 5, 4, 3, or 2 mm. In someembodiments, the rectilinear cross-sectional profile can be triangular,square or rectangular. In some embodiments, the implant structure 800can have a substantially rectilinear cross-sectional profile formed by aplurality of apices that are joined together by a plurality of walls.The thin walled implant structure 800 can be advanced through the bonewith little to no bony preparation. For example, in some embodiments,the implant structure 800 can be driven into the bone without firstforming a bore that is shaped like the implant structure 800. In someembodiments, the distal end 804 of the implant structure 800 can besharpened and/or have cutting edges like a chisel to facilitate thecutting of bone as the implant structure 800 is advanced. In someembodiments, an osteotome can be used to cut the bone before the implantstructure 800 is inserted into the bone. For example, an osteotome asdescribed in U.S. Provisional Application 61/800,966, titled “SYSTEMSAND METHODS FOR REMOVING AN IMPLANT” and filed on Mar. 15, 2013, whichis herein incorporated by reference in its entirety for all purposes,can be adapted to pre-cut the bone to facilitate insertion of theimplant structure 800 without forming a complete bore. In someembodiments, a bore can be formed as described above, and the implantstructure 800 can then be inserted into the bore.

In some embodiments, as illustrated in FIGS. 8A and 8B, the distalportion of the plurality of walls 802 forming the implant structure 800can have fenestrations 806. For example, the distal portion of theimplant structure 800 that is configured to be embedded in the sacrum orsecond bone segment can be fenestrated, while the proximal portion ofthe implant structure 800 that is configured to be embedded in theillium or first bone segment can be free from fenestrations. In otherembodiments, the proximal portion of the implant structure 800 can befenestrated while the distal portion of the implant structure 800 can befree from fenestration. In other embodiments, as illustrated in FIGS. 9Aand 9B and the other embodiments described herein, the fenestrations canbe distributed across the entire face of each wall or side of theimplant structure. In some embodiments, the concentration or number offenestrations can be higher in one portion of the implant structure thanthe other.

In some embodiments, as illustrated in FIGS. 8A and 8B, thefenestrations 806 can be oval or circular shaped or curvilinear, suchthat the fenestrations 806 do not have corners. In some embodiments, thefenestrations 806 can be staggered, arranged randomly, or otherwisedistributed in a non-aligned pattern across each wall 802. For example,in some embodiments, each longitudinal row of fenestrations can bestaggered or offset from adjacent longitudinal rows of fenestrations. Insome embodiments, the fenestrations can alternatively or additionally bestaggered along the longitudinal axis of the implant structure 800. Thisnon-aligned arrangement of fenestrations can provide the implantstructure with improved structural strength.

In some embodiments, the implant structure 800 can be sized as any otherimplant structure described herein. In some embodiments, the implantstructure 800 can be sized so that the implant structure 800 has wallsthat inscribe a circle with a diameter of about 8 mm, or between about 4and 12 mm, as illustrated in FIG. 8B. In some embodiments, the implantstructure 800 can be sized so that the wall inscribe a circle with adiameter equal to or about equal to the diameter of a guide pin. In someembodiments, the implant structure 800 can have a proximal end 808having a cap 810 with a circular opening 812 that allows passage of aguide pin.

In some embodiments, as illustrated in FIGS. 9A and 9B, the implantstructure 900 can be similar to the embodiment described in FIGS. 8A and8B except that the fenestrations 902 are evenly distributed across thefaces of the implant structure. FIG. 9B illustrates bone growing withinand/or through the fenestrations 902 and lumen of the implant structure900. In some embodiments, the bone illustrated within the lumen of theimplant structure 900 may be native bone that remains after the implantstructure 900 is advanced into the bone, i.e. a self-grafting implant.In some embodiments, the lumen of the implant structure 900 illustratedin FIGS. 9A and 9B, as well as the other implant structures describedherein, can be filled with bone material and/or a biologic aid such asmorselized bone, allograft bone, autograft bone, hydroxyapatite, bonemorphogenetic protein and the like to promote bony ingrowth within theimplant structure 900. This can be appropriate when the implantstructure 900 is inserted into a bore such that after implantation, thelumen of the implant structure 900 is empty or substantially empty andcan be filled with bone growth promoting materials. In addition, asdescribed above, the interior surface and/or the outer surface of theimplant structure can be roughened and/or coated, using a plasma coatingprocess for example, to provide a porous or roughened surface.

The terms “about” and “approximately” and the like can mean within 10,20, or 30% of the stated value or range.

Variations and modifications of the devices and methods disclosed hereinwill be readily apparent to persons skilled in the art. As such, itshould be understood that the foregoing detailed description and theaccompanying illustrations, are made for purposes of clarity andunderstanding, and are not intended to limit the scope of the invention,which is defined by the claims appended hereto. Any feature described inany one embodiment described herein can be combined with any otherfeature of any of the other embodiments whether preferred or not.

It is understood that the examples and embodiments described herein arefor illustrative purposes only and that various modifications or changesin light thereof will be suggested to persons skilled in the art and areto be included within the spirit and purview of this application andscope of the appended claims. All publications, patents, and patentapplications cited herein are hereby incorporated by reference for allpurposes.

1-34. (canceled)
 35. A method of stabilizing a sacroiliac (SI) joint,comprising: applying an axially directed, non-rotational, force toadvance an SI joint implant laterally through an ilium, across an SIjoint, and into a sacrum, the implant comprising an elongate body havinga longitudinal axis, a distal end, a proximal end, a triangularcross-sectional profile in a proximal half of the elongate body and in adistal half of the elongate body, and a plurality of fenestrations, andwherein the elongate body has a bending strength or a shear strength ofat least 0.5 relative to a reference elongate body with identicaldimensions and material composition but without any fenestrations;positioning the distal end of the elongate body in the sacrum, theproximal end of the elongate body in the ilium, and the elongate bodyacross the SI joint.
 36. The method of claim 35, wherein the elongatebody further includes an axially-extending central lumen disposed aboutthe longitudinal axis, and wherein the plurality of fenestrations doesnot extend to the central lumen.
 37. The method of claim 35, whereineach of the plurality of fenestrations extends inwardly at an angle thatis substantially perpendicular to a side of the elongate body.
 38. Themethod of claim 35, wherein each of the plurality of fenestrationsextends inwardly at an angle that is not substantially perpendicular toa side of the elongate body.
 39. The method of claim 35, wherein each ofthe plurality of fenestrations has a curvilinear configuration.
 40. Themethod of claim 35, wherein each of the plurality of fenestrations, in aside view, has an oval configuration.
 41. The method of claim 35,wherein at least some of the plurality of fenestrations are randomlyarranged on a side of the elongate body.
 42. The method of claim 35,wherein at least some of the plurality of fenestrations are arranged inone or more rows along a length of a side of the elongate body.
 43. Themethod of claim 35, wherein the distal end of the elongate body has atapered configuration.
 44. The method of claim 35, wherein the elongatebody further comprises an axially-extending central lumen disposed aboutthe longitudinal axis, and wherein the plurality of fenestrations extendto the central lumen.